Unpredicted Bilateral Device Breakage during Active

Phase of Mandibular Distraction: A Case Report and

Literature Review
• Distraction osteogenesis is a biologic process of new bone formation
between the surfaces of bone segments that are gradually separated by
incremental traction. Specifically, this process is initiated when distraction forces
are applied to the callus tissues that connect the divided bone segments, and
continues as long as these tissues are stretched. The traction generates tension
that stimulates new bone formation parallel to the vector of distraction.

(Samchukov et al., 1998a, 1998b).

Why distraction osteogenesis in mandible?
 Orthognathic surgery vs DO

•Inability to stretch soft tissues

• Surrounding soft tissues cannot adapt to the new position resulting in

degenerative changes, relapse and compromised function and aesthetics

• Most deficiencies involve all three planes; vertical, sagittal and transverse

• Orthognathic surgery can only be taken up after active growth ceases

unlike distraction which can be performed in infancy too.
The other side of the coin..

• There are many complications of mandibular distraction osteogenesis

procedures, but the breakage of distractors during the active
distraction is very rare. Only three reports are there in the literature
mentioning the breakage of distractors in the craniofacial region.

• Device failure accounts for approximately 7.9%.The distractor failure

includes either breakage or dislodgement of distractor during the
active distraction procedure. According to Master et al., device
breakage occurred in 4.5% of cases, and it could happen with both
external and internal distractors.
Specific problems in DO

• Anatomy may not be conventional therefore more risk of damage to

nerves or vessels.
• Difficult to place device if bone quality / quantity poor.  
• Improper placement more likely.
• Damage to tooth buds in young patients.
Summary of Distraction Device Breakage Reported in The Literature

Author/Year Journal Name Type of Paper Number of Case Type of Device Area Involved

Uckan S et al. 2006 Oral Surg Oral Med Oral Case report 1 Internal Mandible(Midline)
Pathol Oral Radiol Endod
2006

Jung Ah Lee et al. 2008 Pediatric Neurosurgery Case report 2 Internal Cranium
2008

Tomonao Aikawa et al. Oral Surg Oral Med Oral Case Report 2 Internal Maxilla
2008 Pathol Oral Radiol Endod
2008

Our case   Case Report 1 Internal Mandible

2020
Device selection: What's wrong with internal distractor?
Adulthood presentation of the neglected childhood : A triad of TMJ ankylosis

• A 21-year male patient reported with the chief complaint of unable to

open mouth since the birth, unpleasant appearance of the face, and
unable to sleep properly at night. Parents revealed that he snores
severely during sleep. There was a normal vaginal delivery of the
patient. On extra-oral examination, there was a mandibulofacial
asymmetry with chin deviation towards the right side by 10mm and
convex facial profile with a typical 'bird face' appearance.
• Airway
• Nil mouth opening
• Cosmetic deformity
PRE SURGICAL WORKUP

• Concerns in TMJ ankylosis: Focus in primary requirement

• Diagnostic workup
• Treatment options: Different schools of thought
• Choice of distractor
• Vector control
• Technique
• Anesthesia/Tracheostomy?
• Perioperative care
• Outcome assessment
INVESTIGATIONS

• Blood investigation: Low HB,PCV

• Panoramic radiograph, lateral cephalogram
• CT Face with 3D Reconstruction
• Cephalometric analysis
• Overnight polysomnography (PSG) report showed moderate
obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI)
score of 26 per hour.
TREATMENT PLANNING: Why distraction first?[Kabans protocol,2009]

• The treatment objectives included the lengthening of mandibular ramus

and body, improvement of upper airway dimensions, adequate mouth
opening, achieving a pleasing facial aesthetic, and improvement of dental
and periodontal health.
• Two stages of surgical planning were carried out.
• Stage-1 involved bilateral mandibular distraction osteogenesis for the
lengthening of mandibular ramus and body, improvement of upper airway
dimensions, and facial aesthetics.
• The objective of Stage-2 was to improve mouth opening by Interpositional
gap arthroplasty and facial aesthetics by advancement genioplasty.
SK Surgicals (pune,india)

Distraction plan:

Left side: 19mm

Right side: 26mm.

Distraction rate 1mm per day

( .5mm morning + .5 mm evening)

First 10 mm advancement B/L

Next – differential advancement is
done.
25mm internal mandibular
distractor Clinically mandibular midline is
seen and changes made
accordingly.
• On the 10th day, the patient reported with a complaint of severe pain
and swelling in the lower jaw. On clinical examination, no resistance
was felt while activating the distractors. The OPG revealed bilateral
breakage of the distractors.

Who’s Fault is It?-the blame game!!

Complications vs Error!!
What's Next..

• The broken distractors were removed and replaced by new devices (25
mm intraoral mini distractor for mandible (Orthomax, India). The
osteotomy was done again and active distraction was continued after the
latency period of 5-days. On the right side, the device was activated for a
more period compared to the left side.
• The distraction was continued till an edge to edge incisor relationship was
established and midline was matched.
• After 4-months of the consolidation period, stage-2 surgery was carried
out, which involved the removal of distractors, interposition gap
arthroplasty of right TMJ, bilateral coronoidectomy, and advancement
genioplasty. An inter-incisor mouth opening of 36mm was achieved.
Finally..

• The improvement in facial esthetics, mouth opening, mastication, and

sleeping was highly satisfactory to the patient. The patient is advised
comprehensive orthodontic treatment for further occlusal
management.
 Untangle The Fault Knot..
• The breakage of a distractor is multifactorial. The possible etiology and
prevention of distractor breakage are summarized below.
[A] Poor quality of a distractor
• Selection of a good quality Food and Drug Administration (FDA) approved
mandibular distractors would be the foremost important step towards the
success of distraction osteogenesis. Locally made distractors are usually of poor
quality and might break during the active distraction process. Currently, single
vector internal distractors are the device of choice for mandibular distraction.[3]
The cost of FDA approved mandibular internal distractors is very high that
compels many surgeons to use locally made non-certified distractors. Thus good
quality distractors must be chosen for the success of the distraction osteogenesis
procedure
[B] Microscopic crack on the distractor device
• The excessive adaptation of plates for their optimum fit over the bone
surface may lead to the development of microscopic cracks in the
distractor device.[8] These cracks usually develop at the weakest
point of the distractor, i.e. at the junction between the fixed block and
screw hole extensions.[8] These microscopic cracks might create a
pathway for biological fluids to enter into the device leading to
corrosion and their further propagation and subsequent failure. Thus
excessive intra-operative manipulation of the distractors should be
minimal to prevent their breakage.
[C] Inappropriate distractor vector
• In cases of bilateral mandibular distraction, right and left distraction
vectors should be parallel to each other for similar force resistance.[8]
The unparallel vectors can increase the tension and hinder the
distractors from proper expansion, which, if unsettled, afterward, might
cause distractor breakage. Thus the distraction vectors in bilateral
mandibular distraction cases must be evaluated accurately before the
procedure. The stereolithographic model can help in guiding the
operator for accurate device placement and vector determination. This
would also help in preventing unnecessary device manipulation.
[D] Wrong distraction protocol
• Appropriate rate and rhythm of distraction are critical to prevent premature
bone consolidation.[9] A long latency period would result in the consolidation
of bone, leading to more resistance and device breakage. Also, the wrong
activation may cause undesirable stress and strain at the device's weakest
point and lead to subsequent failure. Thus the activation of a distractor should
be carried out by the same individual rather than by multiple caregivers. Lee et
al.,[8] performed the craniofacial distraction in craniosynostosis cases and
suggested that increasing the rate of distraction, and by placing more durable
devices could prevent the breakage of distractors. They also stated that a slow
rate of distraction could result in the fusion of expanding bones, increasing
resistance, and tension in the device, leading to its breakage.[8]
[E] Tissue resistance
• Incomplete osteotomy and resistance from adjacent soft tissue like
periosteum, muscles, and connective tissue can create excessive
resistance to withstand the stress inside the device. Excessive stress can
cause device fractures.[8] Chin et al.,[10] stated that the resistance of
scalp soft tissue in craniofacial distraction was one of the potential
factors for device failure. Thus the completeness of the osteotomy
must be checked manually during the operative procedure before the
placement of a distractor. If excessive resistance is felt during the
activation, then further activation of the device should be stopped and
checked for the cause of resistance.
[F] Abnormal chewing habit
• Unilateral chewing of hard food might produce a jiggling type of force
on the distractors leading to their breakage
• Although distraction osteogenesis technique has great potential with
several advantages over conventional orthognathic surgery, it carries
many inherent complications. Device breakage is a rare complication
of distraction osteogenesis procedure. Appropriate pre-operative
planning, choosing a suitable distractor device, and distraction
protocol are the keys to the prevention of such rare complications.
Future Concept

• Endoscopic technique
• Resorbable device
• Osteotomy free distraction across suture sites in infants
• VGEF adenovirus & BMP-2 adenovirus show earlier ossification
• Endothelial progenitor cells (Adult stem cells)
“Mistakes are perspectives. It is a learning curve!“